Informed Consent For Laser Hair Removal INSTRUCTIONS This informed-consent document has been prepared to help inform you about laser procedures, its risks, as well as alternative treatment(s). It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by us and agreed upon by you. GENERAL INFORMATION Trying to get rid of unwanted hair on the face or body is a common problem. Laser hair reduction offers results that cannot be achieved with conventional shaving or waxing. The laser works by targeting the hair in the follicle, below the skin's surface. The lasers we use in our medical spa are FDA approved and safe and effective. The laser energy is transformed into heat, which destroys the hair follicle leaving the surrounding skin unaffected. Facial areas, bikini area, upper and lower legs, arms, chest, and back may be treated leaving skin smooth, stubble free and without the irritation of ingrown hairs. In an hour or less, most body areas can be hair free. While some areas of the body are more sensitive than others, most patients report little or no discomfort. Again, this is a no down time procedure. Hair grows in cycles. A minimum of four to six treatments will be necessary, as the process is most effective on hair during the early growth cycle. After each session, you will see substantial visible hair reduction. Each laser hair removal treatment will result in a hair growth reduction. Additionally, hair will grow progressively slower, lighter, and finer with each treatment. It takes more than one treatment to affect all the follicles growing in an area. The number of sessions will vary for each individual. During the initial visit, the laser light disables those follicles in the "active" phase of the growth cycle. Follicles in the "dormant" phase will not be affected. Since follicles cycle through "active" and "dormant" phases, additional sessions may be desired once the "dormant" follicles become "active". For this reason, we recommend a series of treatments. Most people achieve satisfactory clearance after four to six treatments, but individual results may vary depending on medical and genetic factors. Lighter colored hair may require more treatments than darker colored hair. Since no procedure can guarantee permanent hair removal, most patients can expect a sixty to seventy percent reduction in hair growth. Remember the laser is FDA approved for permanent hair reduction not removal. The extent of long-term hair reduction will vary among clients because of the nature of hair and the many factors that influence the growth of hair. After the initial full course of treatments, there should be little hair re-growth. This regrowth will require future laser hair removal treatments to sustain hair reduction. Note: Multiple treatments will be required to achieve optimum results, All payments are strictly non refundable. ALTERNATIVE TREATMENTS Alternative forms of treatment include not undergoing the proposed laser procedures like razors. Page 1 of 5
Instructions Pre-Treatment Avoid tanning for 2 months Avoid waxing, tweezing or depilatory use for 6 weeks Avoid irritants such as products containing glycolic acid or Retin-A in the area for 5-7 days. No Accutane for 6 months prior to treatment Shave the desired treatment area the night before laser treatment. No deodorant, creams, oils, perfumes, etc on area prior to treatment Wear loose, comfortable clothing on the day of treatment, so as not to irritate the treated area Post-Treatment The areas treated with the laser may be red following treatment. This will generally fade within 2-3 days. The treated area can be washed normally with mild soap and water. Wash the area gently with your fingertips. Use of a washcloth or other abrasive instrument is not recommended. Cover the treated area with a sunscreen of SPF15 or higher and avoid sun exposure to the treated area for 4 to 6 weeks. No direct sun exposure for at least 2 weeks Avoid irritants such as products containing glycolic acid or Retin-A in the area for 5-7 days. No deodorant to treated area for 48 hours Minor crusting or scabbing of the treated area can occur following treatment. Do not rub or pick the scab. Wash gently with fingertips and mild soap. Apply an antibacterial ointment to the treated area. Apply 1% hydrocortisone or Aloe Vera to treated area as redness occurs Hair remaining in the follicle will extrude typically within 1-2 weeks after treatment. This will look like growth, but is simply the body's way of eliminating the hair from the injured follicle. On the third day posttreatment, you may shave or gently wash the area to help loosen hair that is still embedded in the follicles. No exercise until perifollicular edema (red bumps) resolves No Jacuzzi, sauna or steam baths until the skin is back to normal Page 2 of 5
Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. The following are some of the risks. Scarring- Although good wound healing after a procedure is expected, abnormal scars may occur within the skin and deeper tissues. In rare cases, keloid scars may result. In some cases scars may require surgical revision or treatment. Burns- Laser energy can produce burns. Additional treatment may be necessary to treat laser burns. Accutane (Isotretinoin)- This drug may impair the ability of skin to heal following treatments or surgery for a variable amount of time even after the patient has ceased taking it. Individuals who have taken this drug are advised to allow their skin adequate time to recover from Accutane before undergoing laser treatment procedures. Fire- Inflammable agents, surgical drapes and tubing, hair, and clothing may be ignited by laser energy. Laser Smoke (Plume)- Laser smoke is noxious to those who come in contact with it. This smoke may represent a possible biohazard. Infection- Although infection following laser skin procedures is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus or zoster infections can occur following a laser treatment. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary. If you have cold sores, herpes or zoster, do please tell us prior to the laser treatment. Medications must be prescribed and taken both prior to and following the laser treatment procedure in order to suppress an infection from this virus. Damaged Skin- Skin may heal abnormally or slowly following treatment by lasers or other surgical techniques. The occurrence of this is not predictable. Additional treatment may be necessary. Skin Contour Irregularities- Contour irregularities and depressions may occur after surgery. Visible and palpable wrinkling of skin can occur. This may improve with time, or it can be surgically corrected. Pain- You may experience some mild pain after the laser treatment. Chronic pain is very rare. Unsatisfactory Result- Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. This would include risks such as unacceptable visible deformities, skin slough, loss of function, poor healing, wound disruption, permanent color changes in the skin and loss of sensation. Additional procedures may be needed to attempt to improve your results. Lack of Permanent Results - Laser hair removal is not permanent. Most clients however can expect permanent reduction of hair. Visible Skin Patterns- Laser procedures may produce visible patterns within the skin. The occurrence of this is not predictable. Distortion of Anatomic Features- Laser procedures can produce distortion of the appearance of the eyelids, mouth, and other visible anatomic landmarks. The occurrence of this is not predictable. Should this occur, additional treatment including surgery may be necessary. Skin Discoloration / Swelling- Some swelling normally occurs following laser procedures. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods and, in rare situations, may be permanent. Page 3 of 5
ADDITIONAL TREATMENT NECESSARY There are many variable conditions which influence the long term result of laser procedures. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with these procedures. Other complications and risks can occur but are even more uncommon. Should complications occur, additional surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained. PATIENT COMPLIANCE Follow all instructions carefully; this is essential for the success of your outcome. Postoperative instructions concerning appropriate restriction of activity, use of dressings, and use of sun protection must be followed in order to avoid potential complications, increased pain, and unsatisfactory result. It is important that you participate in follow-up care, return for aftercare, and promote your recovery. FINANCIAL RESPONSIBILITIES You acknowledge that you have been informed about its risk and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments. Page 4 of 5
DISCLAIMER Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s), including no surgery. The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed-consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. We may provide you with additional or different information which is based on all the facts in your particular case and the current state of medical knowledge. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the consent. I have read and understand the following Informed Consent Material for my specific procedure: LASER HAIR REMOVAL The risks, benefits, and alternatives of the procedure(s) were explained to me. I understand the specific risks in the consent material for my surgery and understand the significant risks of bleeding, burn, infection, injury to neighboring structures, capsule contracture(if implants involved), asymmetry, pulmonary emboli, deformity, healing problems, poor scars, loss of sensation(feeling), appearance/psychological changes, unsatisfactory result, need for future revision surgery and anesthesia. I understand the anticipated results and limitations of the surgery procedure(s). I have realistic expectations and realize that there are no guarantees in plastic surgery. The following instructions were explained to me: Pre and Post procedure instructions, DVT prevention instructions, and medications to avoid instructions. I agree to follow all instructions, to follow up as directed, and to notify the office if any problems or questions arise. Sign Witness Page 5 of 5